Rüdiger Lohlker (Vienna University)

Music Therapy and Mental Health Mental Health Care and Bimaristans in the Medical History of Islamic Societies

Even recent studies on the histories of hospitals only have few pages on Islamic hospitals.1 Thus, it is necessary to turn to a thorough study of Islamic hospitals as an important element of a global history of hospitals and health care. There are other names for hospitals in Islamic times, but this study will use the term bīmāristān to identify these institutions. Our focus will be on mental health and bīmāristāns another field still underresearched.2 Recent studies claim that going beyond the classical studies of ideas of medicine and leaving the old paradigms of Islamic exceptionalism behind, would allow for an integration of the study of medicine in Islamic societies into the field of science studies3 and for a better understanding of the institutional contexts of medical practice.4 Understanding the history of Islamic hospitals means turning to pre-Islamic times.5 We could turn to pre-Islamic Arabia6, but more important may be the Eastern part of what was to be the Islamic world. Thus, we will be able to look into the institutional contexts of Islamic medicine7 – and especially its aspects related to mental health.8

1 In numbers: four pages, thus, excluding Islamic institutions from a general history of hospitals (Risse 1999). 2 Thanks to Margareta Wetchy for her valuable comments. Thanks also to the organizers from the Austrian Academy of Sciences of the Maimonides Lectures 2019 in the Austrian city of Krems who gave the opportunity to present a first version of these ideas. Many thanks to Salim al-Hassani for inspiring some modifications of my argument. 3 Brömer 2010 and Northrup 2013. cf. Gran 1998, pp. 165Sqq. for a – seldom referred to – first attempt of an advanced analysis of medical literature. 4 For the time being we are lacking a reconstruction of the perspective of patients. 5 For a recent conceptualization of this period see Al-Azmeh 2014a and Al-Azmeh 2014b. 6 Female physicians and healers are well known in pre-Islamic times in Arabia (Shehata 2007-2008: 10-11). A thorough history of female physicians in Islamic healthcare is still missing. For male physicians in pre-Islamic times we would have to turn to the chapter on the Classes of Physicians in the time of the rise of Islam in Ibn Abī Uṣaybiʿa‘s famous history of physicians. However, there is some legendary material in it (Ibn Abī Uṣaybiʿa 1965 and Ibn Abi Usaibia 2020). 7 For an overview see Savage-Smith 2007. Older, but including more aspects see Ullmann 1997. For one treatise from Egypt see Dols/Gamal 1984. A highly valuable volume with many interesting chapters is Pormann 2011. 8 Mental health may be contextualized in recent discussions on „bodily experience“ (körperliche Erkenntnis) to inscribe into broader phislosophical discussions; see the contributions in Bockrath/Boschert/Franke 2008. For a recent overview of research on mental health and religion see Classen 2014. On the History of bīmāristāns

A historical view will have to start from the assumption that there have been pre-Islamic precursors to the bīmāristān. These hospitals are not a genuine Islamic invention. The most important pre- Islamic hospital may be the Gundishapur hospital of Iranian and Syriac origin.9 Older research and research based on the older research literature claims: „Without doubt it is on Hārūn al-Rashīd (170/786-193/809) that the merit falls for having founded the first hospital to have functioned in the Islamic world.“10 But there is another (hi)story to be told. As Michael W. Dols and others wrote, the conventional history of bīmāristāns „bristles with difficulties“.11 This is not the place to follow the detailed argumentation of Dols on the pre-history of the bīmāristān and, esp., the Syriac influence. Dols sets the date for the foundation of the first Islamic hospital „in the first decade of the ninth century A. D.“12 Another question arising from earlier research is whether it would be adequate to say Gundishapur should be regarded as a „provincial backwater“.13 There are indeed indications that Gundishapur may have played a certain role in the history of medicine.14 Even accepting that Gundishapur was not as important as some researchers15 want it to be, we may interpret the historical discussions about the historical importance of institutions as part of intra-professional discussions about giving precedence to adherents of Graeco-Arabic traditions, Syro-Arabic traditions, Iranian or even Indian traditions.16 Thus, Gundishapur may be understood as a stake in symbolic games by Syriac physicians and not discussed in terms of historical truth.17 This argument may be supported if we read:

„The kings of the Persians (ʿajam) used to divert the melancholic (maḥzūn) by listening to music (samāʿ), to distract the sick (marīḍ) and to keep him away from negative thoughts.“18

Thus, even the assumption of the existence of an ancient tradition of music therapy (see below) in Iran may lead us to understand Gundishapur as a prime symbol of the mythology19 of medical

9 See for later hospitals in Iran often called dār al-shifāʾ Tadjbakhsh 2012 and Floor 2012. 10 Micheau 1996: 991. 11 Dols 1987: 369. 12 Dols 1987: 382. 13 Vivian Nutton quoted in Nayernouri 2017. 14 Following Nayernouri 2017. See, esp., Shahbazi/Richter-Bernburg 2012. 15 Some of them even misquoting other research literature. See Miller 2006 quoting Dols 1987 (leaving aside some other mistakes included as to numbers, etc.). 16 The Indian influence on Persian medicine in Islamic times has been analyzed by Speziale 2018. 17 Thus, it may interesting to follow the idea of Tabaa reading the Abbasid support for hospitals as an attempt to „outshine the glory of the Sassanian kings“ (Tabaa : 98) and to claim the heritage of the previous dynasty by contructing a genealogy back to Gundishapur. 18 al-Jāḥiẓ 1965: 286. 19 Evidently, I am referring to the excellent chapter of Ragab 2018: 140. expertise. A passage from a literary work illustrates how much physicians from Gundishapur are imagined to be searched for.20 And it will indicate how intercommunal tensions amongst practitioners worked:

„He [sc. Asad ibn Ǧānī] was a physician. Once business was slow, so someone said to him: „It is a plague year, disease rampant everywhere, and you are a knowledgeable man with steadfastness, experience, and clear understanding. How does it come about that you have this dearth [of patients]?“ To which he replied: „For one thing, people know me to be a Muslim, and have held the belief, even before I began to practice medicine, no indeed before I was born, that Muslims are not successful in medicine. Then, my name is Asad, when it ought to have been Ṣalīb, Ǧibrāʾīl, Yuḥannā, and Bīrā [i. e., Christian or Jewish names]. My surname is Abū l-Ḥāriṯ, but it ought to have been Abū ʿĪsā, Abū Zakarīya, and Abū Ibrāhīm [i. e., Christian or Jewish surnames]. I wear a shoulder mantle of white cotton, yet my shoulder mantle ought to be of black silk. My pronunciation is that of an Arab, when my dialect ought to be that of the people of Ǧundaisābūr [i. e., Christian physicians].“21

Why the death of the last leading physician of the bīmāristān of Gundishapur, Sābūr ibn Sahl (d. 869)22 who moved from Gundishapur to Baghdad to join the circle of medical advisers to the then Abbasid caliph meant the death of the institution is not clear.23 What is the origin of the name of the institution? It can be derived from the Persian for sick, bīmār, and the suffix, -stān, denoting place; the short form is māristān. For a sketch of the role of the bīmāristān we will turn to the description of Savage-Smith:

„The Islamic hospital served several purposes: a centre for medical treatment, a convalescent home for those recovering from illness or accidents, an insane asylum and a retirement home giving basic maintenance needs for the aged and infirm who lacked a family to care for them. In the first two instances, admission would be for a limited period of time, with the view of curing a particular disorder. In the last category, it is unclear how many, if any, were of the truly indigent and uneducated classes. […] It is most unlikely that any true wealthy person would have gone to a hospital for any purpose, unless they were taken ill while travelling far from home. Except under very unusual circumstances all the medical needs of the wealthy and powerful would have been

20 There would be an interesting history to tell about the distinctions between professional physicians and charlatans. We cannot tell it here, see for this aspect of medical history Pormann 2005. 21 Pormann 2005: 221. The translation from Jahiz‘ Kitab al-Bukhala‘ by Serjeant has been slightly adopted by Pormann; cf. Taylor 2010: 1 and Dols 1987: 381sq. for the context of the story in Jahiz‘ book. 22 See for him Kahl 2009. Cf. Lev/Chipman 2007. 23 Shabazi/Richter-Bernburg 2012. administered in the home or through outpatient clinics dispensing drugs. […] The care for the insane in hospitals was unprecedented and an important part of even the earliest Islamic hospitals.“24

We cannot give a narrative of the history of the bīmāristān as an institution here.25 We may mention just one important type of bīmāristāns, the bīmāristāns for the care for mentally affected patients. This may have been an important function of these hospitals. Frequently in big bīmāristāns there were special places isolated by iron bars for aggressive patients protecting other patients and visitors from them (see below). Being aware of the requirement of special care for these diseases the physicians had to know the etiology of these diseases. Other types of bīmāristāns included leprosy bīmāristāns, road bīmāristāns, prison bīmāristāns and mobile bīmāristāns.26 These two last types of bīmāristāns can also be dated back to the tenth century AD:

„According to some accounts, directions were given by a wazīr in the early fourth/tenth century to provide medical care to prisons on a daily basis and visits to doctors with a travelling dispensary to villages in lower Iraq.“27

Treatment of sick people in bīmāristāns

The famous author and traveler al-Ḥasan b. Muḥammad al-Wazzān al-Fāsī (d. around 1540), known in Europe as Leo Africanus28, gives a vivid description of a hospital in the city of Fez, nowadays in Morocco. He has worked there for some time and writes29:

„Howbeit there is another hospital for the releefe of sick & diseased strangers, who haue their diet onely allowed them, but no phisition or medicine: certaine women there are which attend vpon them, till they recouer their former health, or die. In this hospitall likewise there is a place for franticke or distraught persons, where they are bound in strong iron chaines ; whereof the part next vnto their walks is strengthened with mighty beames of wood and iron. The gouernour of these distraught persons, when he bringeth them any sustenance, hath a whip of purpose to chastise those that offer to bite, strike, or play any mad part. Sometimes it falleth out that these franticke people

24 Savage-Smith, Medicine, 933sq. 25 Important insights may be gained from Ragab 2015. 26 Al-Ghazal 2007: 6sqq.; cf. Weisser 1991: 6. 27 Savage-Smith 1996: 934 28 See Davies 2008. 29 In older English; we refrain from putting into standard English to avoid a distortion of the atmosphere of this description. will call vnto them such as passe by ; declaring how vniustly they are there detained, and how cruelly they are handled by the officers, when as notwithstanding they affirme themselues to bee restored vnto their right minde. And hauing thus perswaded the commers-by, approching neerer and neerer vnto them, at length they take hold with one hand on their garments, and (like villans) with the other hand they shamefully defile their faces and apparell with dung. And though all of them haue their priuies and close stooles, yet would they be poysoned in their owne filth, if the seruants did not often wash their lodgings : so that their abhominable and continuall stinke is the cause why citizens neuer visite them. Likewise this hospitall hath many roomes for the purueiors, notaries, cookes, and other officers belonging to the sicke persons; who each of them haue some small yeerely stipend. Being a yoong man I my selfe was in his notarie heere for two yeeres, which office is woorth three duckats a moneth.“30

A caricature of the insane in the hospital is to be found in a miniature.31 It shows

„three young men looking through a window at the inmates. Two of the observers make the traditional iconic gesture of astonishment in Islamic art, placing the index finger […] of the right hand to one's mouth, as is frequently seen in the paintings of episodes in the stories of Majnun- Layla and Zulaykha-Joseph. This common gesture may have been apotropaic in early Islamic society, serving as a magical defence against evil when it was apprehended. On the left side of the miniature, a bearded Muslim figure and a young man stand at the entrance of the chamber and also observe the mayhem. The two may simply be visitors, but it is more likely that the bearded man with the staff is the warden of the insane or an administrator of the hospital. […] The scene inside the hospital is quite vivid, showing clearly the chains around the necks of the three violent madmen and the stocks for their restraint. The near-naked appearance of the two of the madmen, especially the exposure of their genitalia, would be quite shocking to Muslim sensibilities – their nudity is a clear sign of their insanity – and there is little doubt about their being Muslims. The peculiarity of the third lunatic is indicated by his grotesque face that resembles the portraits of jinn and divs in Islamic painting.“32

This less idyllic presentation of the reality in bīmāristāns may help to have a more balanced view of the situation of – some – patients and not to create an apologetic view portraying all of the bīmāristāns as a kind of earthly paradise inhabited by – alas! - sick persons.

30 Leo Africanus 2010: 425-426. 31 Similar representations may be found in plays for puppet theatres (see Dols 1995: 131). 32 Dols 1995: 130. For a comparative view of these insane wards in the Islamic world to the situation in Europe we may refer again to Dols‘ reflections:

„Despite the unpleasantness of the hospital conditions described by Leo Africanus, the quarters for the insane were accessible to visitors, and the conditions of the insane appear to have been accepted matter-of-factly. These circumstances do not appear to reflect medieval bedlams offering public entertainment. The sources only mention the visits of men to male patients, and there is no evidence of a prurient interest. The Islamic hospital in general does not fit Michel Foucault's popular interpretation of the function of the hospital movement in seventeenth- and eighteenth-century Europe as the 'great confinement' of the socially undesirable. The Islamic hospital was certainly not intended for the indiscriminate incarceration of the disadvantaged poor, as in pre-revolutionary France. Some patients were neither poor nor disreputable, and the supervision of admissions to a hospital by the local judge in the later Middle Ages would suggest discrimination in the provision of communal welfare. Nor was the confinement great. It is impossible to estimate precisely the numbers of insane patients in the hospitals, but even the greatest institutions, such as the Manṣuri Hospital in Cairo, probably contained only a few dozen insane patients at one time – a very small number in relation to the entire population of Cairo.“33

Thus, having taken some precautions to avoid idealizing misinterpretations, we will continue with the description of the treatment in bīmāristāns. Every bīmāristān had physicians34, male and female nurses. Patients were to be treated regardless of where they came from. In a bīmāristān there often was a garden35, water fountains, and places of worship for patients. From waqf documents and eyewitness accounts we know about the trail of paperwork produced in bīmāristāns. „Physicians were expected to write down descriptions of patients‘ conditions and to keep these records close to patients‘ beds. They likewise had to write down the recipes of medication that they prescribed to patients confined in the bīmāristān.“36 Non-admitted patients could probably get prescriptions in writing. There were separate wards for male and female patients providing care by persons of the same sex; wards for contagious and noncontagious diseases were available, others were dedicated to

33 Dols 1995: 128-129. 34 Some early reports tell of 24 physicians the important ʿAḍudī hospital in Baghdad around 981 CE (Ibn al-Qifṭī 1908: 438, biography of Ibn Mandawayh). 35 For the importance of hortitherapy cf. Bascands 2015. 36 Ragab 2015: 176. ophthalmology, general medicine, surgery, and mental illness. Physicians had to pass examinations37; this holds also true for physicians treating mental illness. Sound treatment of mental diseases required „unbiased clinical observation“38 by the physician to find the right diagnosis.

Body and Soul39

Pauline Koetschet (2018 gives an excellent summary of the medical views on the relation of body40 and soul:

„According to Arabo-Islamic physicians the overall functioning of the body demonstrated the reciprocity of the humours41 on one side and psychological events on the other. This is the reason that primary qualities […] were thought to have a strong influence on an individual‘s moral character […] Conversely, the state of the soul was believed to have an impact on the bodily balance […] Soul-body reciprocity was the reason that the physicians should always particular attention to his patient‘s emotional and spiritual state.“42

This – in modern terms – holistic approach to mental and physical health has a deep influence on the concept of mental health.

„The reciprocity between soul and body becomes crucial in the case of mental illness, where is both crucial and problematic. To my knowledge, maladies of the soul do not correspond to any disctinct category found in medieval medical encyclopedias written in Arabic.43 for most authors of these encyclopedias, the direct causes of all maladies were physical.“44

Thus, we will have to find a new epistemological approach to the mental-physical dichotomy inherited from Western thought – historical and modern – for a better understanding of the body and its mental aspects. Thus, we will finally turn again to mental health!

37 Cf. Weisser 1991 for these way of examining physicians and other ways of education. 38 Meyerhof 1935: 322 with several clinical observations by Abū Bakr al-Rāzī. 39 Turning the title of the chapter of Koetschet 2018 is done intentionally, since for this paragraph we will set the body before the soul due to the preference for physical explanations of mental diseases. 40 This new field of research has been opened by the contributions in Annales Islamologiques 48 (2014). 41 For a critical view of the assumption of the dominance of humoral theory for medical practice see Savage-Smith 2013 (Footnote RL). 42 Koetschet 2018: 60-61; cf. eadem 2008. 43 Although it may be true in terms of quantity, the literature in Persian and Hebrew is an important element of non- modern medical discourses. (Footnote RL) 44 Koutschet 2018: 63. Mental Health and the View of Physicians

There is an Arab saying al-junūn funūn, to be translated in our context as: there are many forms of mental diseases. Looking into medical literature, depressions and melancholy seem to have been wide-spread psychological problems – also called mental problems – in the non-modern Islamic world „The Arab physicians’ accounts of the close correlation between melancholy and the other psychosomatic diseases differ substantially from those given by Rufus and Galen.“45 Abū Bakr al-Rāzī (d. 925) was a court physician in Baghdad and practiced medicine in the new ʿAḍudī bīmāristān. He is known for the central role of experience in his medical methodology and the many case studies he wrote down.

„Even though his understanding of the different kinds of mental patients relies on Greek sources, such as Rufus and Galen, Abu Bakr al-Razi made further distinctions in the categories of mental illness and mental patients found in these sources. In his Comprehensive Book on medicine, which gathers the lecture-notes that al-Razi made on his Greek, Syriac and Arabic sources, he argues against the “common people” (al-ʿamma)’s tendency to characterise any person showing a confused state of mind or behaviour as ‘mad’“46

Al-Razi stressed the difference between melancholy and delirium – contrary to Galen and Rufus – arguing for a

„more limited conception of melancholy that would not include other kinds of mental diseases such as φρενίτις or μανία. In the third chapter of the first book of The Comprehensive Book on Medicine, al-Razi denies that melancholy can be provoked by dark yellow bile. Dark yellow bile can provoke a form of delirium, but this should not be considered as a type of melancholy, as he explains in his Introduction to the Art of Medicine. In the thirteenth chapter of the same book, al-Razi deals with the affections of the faculties of the rational soul. In the part devoted to the affections of thought, he uses the term waswas in the general sense of “delirium”, or “confusion of the mind”. Different forms of delirium include melancholy, φρενίτις, or μανία. When the affection has its origin in the brain (as opposed to the whole body) and is produced by yellow bile, this is a case of φρενίτις (sirsam). Black bile, on the other hand, causes “bestial madness” (al-junun al-sabuʿi).“47

45 Koutschet 2015: 227; cf. Koutschet 2019 for an overview of the position of Abū Bakr al-Rāzī towards Galen. 46 Koutschet 2015: 228. 47 Koutschet 2015: 229. Al-Majūsī (d. 982-95 CE), a representative of Galenism before Ibn Sīnā, talks about different types of melancholia. Black-bile melancholia, e. g., is regarded as a confusion of the reason (ikhtilāṭ al- ʿaql) without fever. Melancholia originates according to al-Majūsī in the stomach, the brain or other parts of the body. Each kind of melancholia has its symptoms. Al-Majūsī is talking about mental confusion, serious delirium, love-madness, anxiety, sadness, fear, terror, suspicion, hallucinations and so forth.48 A very special type of melancholia is mentioned by him:

„One kind of melancholia is said to be lycanthropy. Its victim behaves like a rooster and cries like a dog. He wanders among the tombs at night and stays there until morning. His complexion is yellow; his eyes are dark, brutish, and hollow; his tongue and mouth are dry and lack saliva; and his thirst increases. There are lesions or sores on his body. The ill hardly ever recover, and the disease is hereditary.“49

The interpretation of Isḥāq ibn ʿImrān (d. 932)

„produces roughly the same result, by extending the scope of melancholy to many mental plights. Ishaq lived in Kairouan (in modern Tunisia) at the court of the Aghlabid sultan Ziyadat Allah III, and is the author of the only surviving monograph on melancholy produced in the Islamic medieval world, the Treatise on Melancholy. In this treatise, melancholy covers an extremely wide variety of symptoms, ranging from excessive sadness and fear – the two traditional symptoms attached to melancholy in the sixth book of the Hippocratic Aphorisms – to extreme forms of madness including bestial madness.“50

However, we have to bear in mind the nickname ‚instant poison‘ of Isḥāq ibn ʿImrān because he was often unsuccessful in his treatment. Thus, it may legitimate to question his theories.51 Famous physicians like Ibn Sīna (d. 1037 CE) contributed to the ideas about mental diseases, but we cannot follow these discussions here. Distinctions were made between melancholy and madness as to be seen in diverse case stories.52 Up to the seventeenth century CE there are descriptions of the bīmāristān and its wards for the mentally ill. We have to bear in mind that these institutions were only for those patients with severe diseases; less severe cases were treated in their families. And we have to bear in mind that some

48 Dols 1995: 64-65. 49 Dols 1995: 65. 50 Koutschet 2015: 230-231. 51 Ibn Abi Usaibia 2020 13.1.1 . 52 Koutschet 2015: 238sqq. ways of behaving beyond what was perceived as standard behavior were not considered to be psychiatrized. E. g., Ismāʿīl ibn Ḥammād al-Jawharī (d. 1002 or 1008 CE), the famous lexicographer and author of the Ṣiḥāḥ: Tāj al-lugha wa-ṣiḥāḥ al-ʿarabiyya53,

„stood atop the old Friday mosque in the Northeastern Iranian city of Nishāpūr and looked down at the astonished and bewildered faces of the crowd below him. A moment later, to the utter amazement and horror of his fellow townsmen, he leaped into the sky with artificial wings attached to his arms.“54

His attempt was not successful and al-Jawharī fell down on the earth and was killed. What is interesting for us are the interpretations of his intentions. Some sources tell that he acted out of sudden madness, other sources give other interpretations, e. g., that it has been an unsuccessful attempt to fly. Thus, the jump of al-Jawharī was not understood per se as madness.55 There are many stories about eccentric behaviour of, e. g., Sufis, who were regarded as a kind of ‚holy men or women‘ not as mentally insane.56 Although the behavior of these people may nowadays be regarded as a symptom of schizophrenia, it was accepted with respect and tolerance because of its religious aspect.57

„This acceptance was enforced by one of the most influential Sufis, Ibn al-Arabi (d. 1240 CE58), who wrote, ‚the mystical experience assails a person suddenly and he loses his mind; God speaks through the lunatics. The mad people are God‘s people, the madness is not caused by natural process, it is caused by divine revelation.‘“59

But there are women, too. In a biographical lexicon, we read about a „woman in Giza, Egypt, who stood for a long period in a field without any protection from the sun or the wind. She was fed from time to time, eating whatever was given to her.“60 The Abbasid caliph al-Muʿtaḍid bi‘llāh (d. 902) we are told,

53 al-Jawharī 1979. 54 Leiser 1988: 173; Youssef/Youssef 1996 have a wrong name (Hamad instead of Hammad). 55 Leiser 1988: 173-174 56 See interesting stories in Gramlich 1987. 57 For the spiritual dimensions of health following Sufi views see Cecere 2014. 58 Chronology adopted by the author (RL). 59 Youssef/Youssef 1996: 60; the references to the Futuḥāt in this article are inaccurate. 60 Youssef/Youssef 1996: 60. „was afflicted by a visual experience that manifested itself in several forms. He ordered tie gates of the palace to be guarded and locked from all quarters to protect him from his visual experience. […] It seems also that the Caliph had persecutory delusions. […] Surprisingly, he even brought mentally ill patients from a nearby mental hospital, so that he could trace the source of his illness by calling upon the Jinn of one of the lunatics.“61

Treating Mental Illness

The way the Caliph al-Muʿtaḍid tried to cure his illness was, however, not the usual way of treatment. A more adequate way of treating mental diseases will be described below. Treating insanity and what was regarded as possession did have a long history in South West Asia going back to Byzantine times. But mental illnesses were not always diagnosed in terms of possession as some researchers claim, but there was a capability to distinguish insanity and illness.62 The bīmāristān tradition may claim to be a genuine heir of this tradition. Creating an atmosphere and environment63 that is supportive for the successful treatment of mental illnesses was a core element of treatment in bīmāristāns. Some

„therapies were water-based treatments. Life-giving strength of water always attracted the attention of mankind and all its possible usage methods were developed with a great inventiveness during the different periods of the history and have always received a vital consideration in Muslim countries. At an early stage Muslim engineers were exploring new methods for increasing the effectiveness of water raising machines. The 13th century mechanical engineer Badi’ Al-Zaman Al-Jazari, was responsible for the design of five of these machines. One such machine was located in Damascus in the canal called Nahr Yazid and it is thought to have supplied the needs of the nearby bimaristan Al- Qaymari. Praying five times a day is an important pillar of Islam. It is an Islamic obligation both for ill and for healthy persons. And before praying, where possible, one must wash face, head, hands and feet. So generally, the bimaristan provided the patients and the employees with water reserves and with bathing facilities. Water treatment was used by the Arabic physicians as a mean in order to modify bodily equilibrium. A great importance was given to the temperature of the water as well as to the duration of the bath. Essential oils and aromatic and fragrant essences added to bathwater were also considered beneficial for example to eliminate melancholy. The sound of the water was considered therapeutic

61 Youssef/Youssef 1996: 61. 62 See Horden 1993 challenging conventional views. 63 For a study of the thermal and ventilation aspect of a hospital in Damascus see Maraqa/Van Moeseke/De Herde 2014., too […]. The view and the scent of the plants were considered treatments too and it was believed in particular that the scent of the plants reached the brain and influenced it. The medical treatments used in the bimaristans also included fomentations especially to the head, baths, bloodletting, cupping, bandaging, and massages with different oils, compresses, particular personalized diets. It seems that also ergotherapy was largely utilized and that dancing, theatrical performances, as well as poems and Qu’ran recitation were part of the therapy.“64

Following the evidence from medical texts, drugs were also used to treat mental illness. They were

„usually of vegetable origins, comprised purgatives, sedative (especially opium) digestive and emetics. They were used both as simple and as composed products and were used to stimulate the apathetic, to soothe the violent patients and to support the depressed persons.“65

Flowers were another essential part of Islamic medical therapy and discussed in handbooks.66 Taking Fakhr al-Dīn al-Rāzī‘s (d. 1210 CE) book on the preservation of bodily health67 we are told that the violet (banafshe) is useful to cure several heath problems:

„It opens warm68 growths, a sore breast is cured, cough and warm and dry headache are eased, conjunctivitis and stomach inflammation are cured. Drinking it eases pleurisy, pneumonia, nephritis or dysuria. The waterlily is like the violet. Smelling and drinking it redices the virility and the sperms, esp., used for the genitals. Narcissus is balanced. Its fragrance eases problems of the brain. Its oil strengthens the tendons. Its seeds close wounds and healstendon injuries. Eating one or two of its bulbs helps vomiting. If the skin of alopecia is grounded with it, the hair will grow again.“69

The list of flowers discussed by Fakhr al-al-Dīn al-Rāzī starts with roses and ends with the cypress. Another importsnt method for treating mental diseases was music.70

Music Therapy

64 Gorini 2007-2008: 17. In Fakhr al-Dīn al-Rāzī‘s handbook for the preservation of bodily health, e. g., we find a similar holistic approach (al-Rāzī 1390h). 65 Gorini 2002: 41. 66 For the role of scents and fragrances see in the Islamic world see Bonnéric 2016. 67 For an overview on the positive and negative effects of scents see the fifth chapter in al-Rāzī 1390h, pp. 49sqq. 68 Referring to the categories accorded to humoral pathology used by Fakhr al-Dīn al-Rāzī we cannot discuss here. 69 al-Rāzī 1390h, pp. 53-54. 70 See Neubauer 2012-2014, Farmer 1930. One of the most important methods to cure mental problems was music therapy.71 There has been an extensive discussion on the philosophical72 preconditions of music therapy.73 Some examples may illustrate positions in this discursive process:

„Both al-Kindi and the Brethren of Purity refer to music therapy as one aspect of the broad philosophical-metaphorical approach that considers harmony in the widest sense as a power involved in mastery of all arts. Originally conceived as such by the (Greek) philosophers, its proper manipulation for purposes of therapy implies a keen knowledge of the laws of universal harmony as well as their reflection in the music made by man. Therefore, this capacity belongs first and foremost to the musician-philosopher, because, as the Brethren say, the science of music is the principal wisdom leading to philosophical thought, and because harmony, wherever it is found in nature, cannot be described without being subordinated to the ideal laws of music. It can be inferred from the foregoing remark made by al-Kindi that the musician should also have some knowledge of medician? What about the physician?“74 […]

Ibn al-Hindū (d. ca. 1019 CE) wrote an encylopedic work Miftāḥ al-ṭibb wa-minhāj al-ṭullāb75 on the disciplines a physician should know to be perfect. The disciplines he mentioned are physics (ʿilm al-ṭabīʿiyyāt), mathematics (ʿilm al-riyāḍiyyāt) with the subdisciplines of arithmetics, geometry, astronomy and music, metaphysics and theology (ʿilm al-ilāhiyyāt). Logic is excluded since it has been discussed by him earlier on.76 As to music Ibn al-Hindū refers to a saying attributed to Hippocrates (buqrāṭ) that the „ancients“ cure the ill (bīmārān) by playing music.77 Another author mentioned the need for the physicians to know about the theory and practice of music, esp., touching the strings of the musical instrument since this may help him to practice pulse diagnosis.78 Eckard Neubauer wrote in his seminal article on Arabic handbooks for music therapy that there are lacunae concerning the selection of modi to be chosen by a musician for the treatment of certain

71 For a general, cross-cultural overview see Horden 2000; cf. Bates/Bleakley/Goodman 2014. Cf. Ka‘bān/Qatāya s. d. for an Arabic language overview. 72 For links to Islamic mysticism/Sufism see Shiloah 2000: 244. 73 We cannot follow this line of thought here. 74 Shiloah 2000: 81. 75 For a short overview see Nasser/Tibi 2007. 76 Ibn Hindū 1422/2002, pp. 81-86; I am following Bürgel/Käs 2016, pp. 134-137. 77 Following Moḥaqqeqī 1988, pp. 239-240, cf. Bürgel/Käs 2016, p. 136. 78 Bürgel/Käs 2016, p. 134. For the special case of the new discipline of Islamic music theory on musical metres (īqāʿ) see Neubauer 2008-2009. diseases.79 Neubauer states that an integrated concept of music therapy like this is unique in the history of music and medicine.80 The oldest textual evidence for practical approaches for a musical theory81 of affects are going back to the 9th century CE but it took several hundred years until a fully developed practical system. Ṣafiyy al-Dīn al-Urmawī (d. 1294 CE) presented in his Kitāb al-adwār (‚Book of Cycles‘)82 an integrated tonal system and a series of twelve main modi (called šadd, pl. šudūd).83 This modi (also called anghām or maqām) were linked to the signs of the zodiac and formed an integrated therapeutical system based on astrological-medical considerations. To give an example taken from an anonymous manuscript: „Iṣfahān stimulates the intellect (yuwarrith al-fiṭna), sharpens the thoughts (yuḥidd al-khawāṭir), makes determined for studying (yuʿayin ʿala ‘d-dirāsa) and cures diseases due to cold and dryness.“84

The selections of the appropriate modes (Arab. maqām) was very important, since the maqām used influences the mood of the patients. One may make the patients laugh, another one lets them fall asleep, gives pleasure or drives fear away. To give an example, the maqām Iṣfahān helps patients with memory problems. Equally important was the time the maqām was played, be it in the morning, at noon or in the evening.85

Maqām Isfahān

Solutions for specific forms of mental diseases have to be found according to the individual dispositions of the patients.86 Music therapy was developing throughout pre-modern Islamic history. An overview of the classification of mental diseases in Ottoman manuscripts provides insights into the theoretical framework of music therapy in Ottoman times. Nil Sari says that most of these diseases are

79 Neubauer 2009: 233-234. Cf. Wright 2004/2005 and Neubauer 2004/2005. 80 Neubauer 1990: 233. 81 For the modern practice of music therapy spreading from Turkey to Austria and other European countries see Güvenç/Güvenç 2009. For some empirical data on the effects of this therapy see Gutjahr et al. 1994. 82 Al-Urmawī 1986; see on him also Arslan 2007. 83 Neubauer 1990: 235. 84 Neubauer 1990: 257 (translation by me, RL). 85 For a general overview see Isgandarova 2015. 86 Sufie/Sidik 2017. classified as illnesses of the head. Some others are regarded as physical illnesses, esp., psychosomatic diseases like hysteria, anxiety or lack of appetite or sexual diseases resulting from mental disorders. Other mental illnesses due to the use of alcohol or opium or other mental or personal disorders are studied separately.87 Taking this into account we will turn to Ottoman music therapy!88

„It was during the Ottoman Empire that music as therapy reached its culmination (Terzioğlu 1985, 16). Evliya Chelebi mentions that in Edirne, Sultan Bayazid II built the state hospital (darüşşifa – the houses of healing) in 1488, where water sound and music therapy were regular prescriptions in the treatment of diseases, particularly in the treatment of mental illnesses. On different days of the week, the music therapy team of the hospital performed for the patients. The doctors, who were also well trained in the effects of music on human health, observed how different melodies (maqams) affected the heartbeat or which melody was suitable for various illnesses. It was generally accepted that the maqam Isfahan benefited patients who suffer from memory problems; the maqam Rehavi was good in the treatment of anxiety; and the maqam Kuchi was good in the treatment of depressive thoughts and dysthymia. Chelebi also reports that another famous ruler of the Ottoman Empire, Bayezid Veli established his own charity hospital and appointed ten musicians, who played in flute (ney), string musical instruments such as santur, keman, cengi, ud, for patients at least three times a week. Chelebi claimed that patients benefited from various maqams, especially from the maqams Zengule and Buselik.“89

This use of music as therapeutical means has been studied by several Ottoman authors in the tradition of al-Fārābī, Abū Bakr al-Rāzī or Ibn Sīnā referring, however, to ancient Turkish ideas about the role of sound and melodies in day-to-day practice.90 As mentioned before, music therapy was used in Ottoman times in a framework informed by theoretical, practical and empirical considerations.91

„The aims of Ottoman music therapy by playing specific modes prescribed for certain physiognomies and nations can be classified as: treatment of mental diseases; treatment of organic diseases; maintaining/re-establishing the harmony of the person – a healthy balance between body, mind and emotions by pleasing him/her; leading the way to emotions, such as getting people laugh

87 Sari 2005. 88 We have to mention the role of women in health care and medical therapy in Ottoman times aptly described by Sari 2009a. 89 Isgandarova 2015: 110-111. 90 It would be desirable to study possible linkages to the East Asian (and South Asian) ideas on health care or music for a better understanding of a global history of medicine. Sari 2009b opensup this perspective. 91 For the Otttoman music therapy see the excellent article Sari 2009b. or making them cry etc., preventing vicious feelings and attracting good ones, training the self and thus reaching perfection.“92

A specific way of treating mental diseases close to music is the use of the recitation of the Qur‘an93 to ease tensions.

Some other aspects

One of the most important aspects of curing diseases in bīmāristāns was based on the Arabic medico-culinary-dietetic tradition.

„In early Islamic times, inherited Greek dietetic theory was wedded to indigenous Middle Eastern culinary traditions, textual evidence for which may be traced to Babylonian times. A dialogue between medical professionals and laymen emerged, each group to some extent informing and being informed by the other. The culinary manuals provide a clue to the nature of this relationship. They point to the central place of the domestic household in the life of the leisured urban class in Islamic societies, where not only proper nourishment could be provided to its members but also remedies for minor ailments or disorders which did not initially, at least, require, the physician‘s expert knowledge of drugs to combat more serious disorders. Healthy food habits were a primary concern of both physicians and household managers, yet the daily supervision of such management was possible with minimum intervention from the physician.“94

The household aspect of proper dietetics95 may be read as an indicator of the importance of private healthcare – even in the case of mental health. Sometimes vegetarian dishes are noted as an important part of the treatment.96 In bīmāristāns this personal relationship between patient and physician so obvious for court physicians was reduced by the control of the bureaucracy of the hospital. Every prescription and medical action has to be documented in written form.97 An important section of the bīmāristān was the dispensatory, sometimes called sharābkhāna, roughly to be translated as room for medical potions, at the same time storage room for drugs, etc.98,

92 Sari 2009b. 93 Nelson 2001 and for a more recent study Babamohamadi et al. 2015; esp., in contemporary Iran there are many studies on the effect of Qur‘an recitation. 94 Waines 1999: 240. 95 Cf. Pitchon 2016. 96 Ibn Abi Usaibia 2020 15.42 . 97 Ragab 2015: 221sqq. 98 For the drugs used see Kahl 2009 and Kahl 2007; cf. Saad/Said 2011. glass vessels, precious instruments, vessels made of porcelain or metal. Medicine was handed by the pharmacist - who is regarded as a technician – according to the prescriptions of the physicians.99 The importance of the pharmacist beyond his duties in the bīmāristān and the hospital being open to visitors may be illustrated by this story:

„The reason al-Rāzī began to study the medical art was that when he first came to the City of Peace, Baghdad, he visited the ʿAḍudī hospital so that he could see it for himself. There he was fortunate enough to meet the hospital’s pharmacist, a venerable man, whom al-Rāzī questioned about drugs and who had first discovered them. […] When al-Rāzī heard this, he was impressed and visited the hospital another time, where he saw a child who had been born with two faces in a single head. Al- Rāzī asked the physicians about the cause of this, and when he was informed he was impressed again with what he had heard and continued to enquire about one thing after another, remembering everything he was told until he decided to learn the medical art and eventually became the ‘Galen of the Arabs’.“100

A short remark about the relation of physicians and alternative practitioners (referring among others to al-Rāzī again) may be appropriate:

„Al-Rāzī complained that women were credited with successfully treating patients while he himself – at least if we are to believe his own account – was really responsible for effecting the cure. Al- Kaskarī displayed a patronizing attitude toward women, whom he perceived to be gullible and ignorant. It is a fair surmise to say that women, whether as midwives, healers, or carers, catered to the medical needs of a substantial part of the community, and were therefore in competition with male practitioners – which could account for al-Rāzī’s prejudices. However, it is difficult to make general assertions about women in medical and paramedical professions in the period and region discussed here, owing to the dearth of research on the topic; female practitioners in the classical period of Islam seem to be one of the blind spots of scholarly attention. In the absence of more sophisticated research, suffice it here to point out that gender was important when physicians demarcated themselves from alternative practitioners.“101

A Deepening of research on this aspect of Islamic medical history is needed.

99 For a excellent overview of pharmacology see Chipman 2018. For the role of pharmacies in Mamluk and Mongol times cf. Chipman 2007 and for examples for prescriptions Chipman/Lev 2010-11 and Lev/Chipman 2012; how to read prescriptions see Chipman 2019a and 2019b. 100 Ibn Abi Usaibia 2020 11.5.2 . 101 Pormann 2005: 226. Storks in Hospital

There is yet another narrative to the bīmāristān! In the bīmāristān of Fez we mentioned before, storks were treated mostly because of bone fractures. Traditionally storks were regarded as „holy birds“, the souls of Muslims incarnated in them, who had not been able to perform the Hajj. As a bird, they were able to fulfill this duty.102 This has to be framed in other narratives on storks and its veneration in the regions of the Western Mediterranean. A traveler in the beginnings of the 19th century wrote about charitable foundations to hospitals in Fez that are dedicated to look after, treat and even bury sick and dead cranes and storks. There is also the idea that these birds are incarnations of men from very distant islands adopting the shape of storks (or cranes) to go there and returning to their human shape.103 The regular migration of these birds makes them an object of special veneration. Turning from birds, folklore and the religious ideas related to it to another religiously imbued act will help to round off the picture of the bīmāristāns.

Politics104 and Hospitals

A final remark may shed some light on the intersection of politico-military efforts and founding a bīmāristān. Under the rule of the Mamluk Qalāwūn (d. 1290) intense warfare against the Il-Khans of Iran took place who were suspected to have Shi‘ite or pagan leanings. The crusader kingdoms in Palestine and Syria were fought against since they were regarded as potential allies of the Il-Khan enemy. These heightened tensions led to attempts to Islamize even the bīmāristāns.105 Thus, building a bīmāristān could be regarded as an act of jihād.106

102 Gorini 2007-2008: 19. 103 Roque n. d.: 104. 104 Being aware that politics may not be the appropriate term for this period. 105 Northrup 2013: 14-15. 106 Northrup 2013: 14. Literature

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